During those months, Dr. Lebowitz was a regular presence, sweeping into the room at unexpected times, casting an appraising eye on her condition and numbers. My son-in-law called him frequently, and he took the calls with patience, knowing how to give firm but compassionate answers. He never gave us false hope, but neither did he discourage us from hoping and praying; he simply tried to do his best for our daughter.

We saw other patients come and go, some back to the hospital, others back home. Spending almost every Shabbos in the bikur cholim house across the street, we met many other frum families with relatives under Dr. Lebowitz’s care. We met a wife from Boro Park whose husband took weeks to come off a respirator, then went through a brief phase of ICU psychosis before he was able to go home. A Sephardic woman from Flatbush came with her husband and his private nurse, also staying a few weeks until he could breathe on his own and be discharged home. An ancient-looking chassidic woman from Williamsburg stayed on the floor until being transferred to a nursing home. Without exception, these and other families said they owed Dr. Lebowitz a huge debt of gratitude.

A Patient-Care Guy

Dr. Lebowitz’s LTAC occupies two floors within Monmouth South Hospital in Lakewood. The 50-bed facility attracts two different populations. About half his patients are non-Jews sent by local hospitals. Their average age is around 70, and they’re typically people who have been difficult to wean off a respirator.

The other half are the frum patients, generally quite a bit older and sicker, who come from Lakewood, Brooklyn, and all over the East Coast. Maimonides Hospital in Brooklyn refers many patients to him — sometimes patients in their nineties. “We take patients that New York hospitals aren’t interested in caring for,” Dr. Lebowitz says. “It’s not just that we’re willing to accommodate halachah. Our mission is to allow families to live in a way consistent with halachah.”

“There are other LTACs, but Dr. Lebowitz is the only frum person running one. He understands the religious mentality,” says Leah Horowitz of Chayim Aruchim. “He’ll put a 98 year old on dialysis. I know of a 97 year old lady who was put on a trach, although doctors said she’d never be able to come off it. Well, five weeks after she came to Dr. Lebowitz, she was completely weaned off.”

Patients are brought in with issues like respiratory failure, preexisting lung disease, malignancies, or stroke. Some arrive when the post-operative course of treatment for cardiac surgery takes a bad turn. “I often help these patients recover,” Dr. Lebowitz says. “Some of them get here with their chests still open.”

Given the age and severity of the cases he accepts, people believe that admission to the LTAC will be the last stop. But this is a misperception. “Close to 80 percent of our patients are discharged to their homes or skilled nursing facilities,” Dr Lebowitz clarifies. True, there is a higher percentage of death among the frum, but that’s because more of those patients come in extremely old and sick.

Many of his patients have been sent on from tertiary care centers where, as Dr. Lebowitz puts it, “The goal is to get through the next shift with as little drama as possible.” But his goal is to run a medically sophisticated operation with a level of care and innovation similar to academic hospitals. He wants Specialty Hospital be a place that tries to move patients forward rather than simply maintaining the status quo or waiting for them to expire. “We want to give patients every possible chance to get better,” he says. Even if it’s just for a few more months.

His patients are fragile, so any misstep can be critical, be it with medication, nutrition, or respiration. He handpicks his staff, which consists of nurses, nurse practitioners, physician assistants, therapists (occupational, respiratory, physical, speech), and wound care specialists. There’s a nurse-to-patient ratio of one to four (by contrast, the average nursing home has one nurse per 12–15 patients), and in contradistinction to other LTACS, Dr. Lebowitz actually employs doctors on staff. (Most LTACs are nurse driven, with doctors only coming in from time to time to consult. “There are national LTAC chains that don’t employ a single doctor,” he claims.) Patients’ vital signs are monitored by telemetry screens, a level of vigilance that rarely exists outside an ICU.

Every Tuesday, Dr. Lebowitz meets with 10 to 20 members of his staff, during which they review patients on the lower floor; Wednesday mornings are for the upper floor. They try to take a step back, perhaps see if the previous facility missed anything in the picture, like an autoimmune problem or atypical pneumonia. Over time, as they treat patients, they gain a clearer sense of each one’s situation. “We try to approach it in a Socratic way, not taking anything for granted, rethinking each case,” he says. And most important, never giving up on anyone.

Urgent care has evolved greatly in the past 25 years. Doctors are better able to control vital functions like blood pressure and heart rate with medications, and the biomechanical devices are better as well. “I just took a call this week about a young person who was put on a ventilator with a trach,” Dr. Lebowitz recounts. “He and his wife had hesitated, believing it’s terrible to be on a ventilator. But now the wife called to say she was very grateful; she had her husband back. Before that, he was struggling for every breath. So these are powerful tools.”

He himself keeps an eye out for ways to innovate in areas like wound care and respiratory therapy. “I have some ideas,” he confesses. “At times I’d love to go back to the lab to research my ideas. But temperamentally, I’m not a lab guy who can work all day with rabbits and mathematical models; I’m a patient-care guy.”

His funding comes largely from Medicare or commercial insurance, with enough of a margin to allow him to occasionally give a break to patients who need it. “Once we accept someone, we try not to let finances get in the way,” he says. “On the other hand, we do have to make sure the lights stay on.”

New Medicare regulations have further limited what the facility can be reimbursed for, and he sometimes fears they’ll end up “one regulation away from insolvency.” For now, however, he has enough of a margin to go the extra mile for patients, like his patient who needs a pill twice a day that costs $150, an expense he says no nursing home would agree to cover.

In general, he feels modern health care has made great strides in terms of preventive care and public health. We’ve learned to encourage mass immunization and healthy lifestyles, and raise awareness about high risk behaviors (e.g., poor diet, lack of exercise). But we put less resources into individual patient care, especially as more primary care is farmed out to mini-clinics and pharmacies.

“Primary care is being dumbed down to the lowest common denominator,” Lebowitz says. “In the old system, you had a family doctor who knew your history. When I began in medicine, the mark of a good internist was the ability to make good diagnoses. That doesn’t happen when medicine consists of sporadic urgent care visits.”

Unexpected Journey

Howard Lebowitz is the black sheep in his family — a frum doctor in a family of lawyers. Originally from the Boston suburbs, he attended Harvard University in the early 1980s when, he says, “Wall Street was on fire. Most of my classmates wanted to work in finance and make big money, but I felt more interested in taking my knowledge and skills to do something meaningful.”

He majored in applied mathematics, and continued at Harvard for medical school, training at Brigham and Women’s Hospital in internal medicine. He also earned a master’s degree from the Massachusetts Institute of Technology division of Health Sciences and Technology, with a thesis that was medically oriented — creating a mathematical model for the interaction between patients and artificial respirators. His first lab job was in biomechanics, applying math and science to help people with disabilities.

He remembers medical school as exhausting. “You resent anything that stands between you and your bed,” he recalls. Yet in the machismo culture of Harvard Medical, it didn’t occur to anyone to complain. “You were supposed to regret missing the calls you couldn’t take on your nights off,” he says. “There was a sense that we were privileged to be there, that we signed up for this, so there was no room to grouse. L’havdil, it was a form of hasmadah — the secular world has its gedolim, we have ours.”

It was during a break before starting his residency that he became “one of those backpacking guys” who took off for Eretz Yisrael. The care of patients and observation of so many critical situations had prompted him to start asking the big questions, and through a series of coincidences (perhaps better described as Hashgachah pratis) he ended up in a classroom at Aish Hatorah.

His journey was similar to the one described by fellow physician Rabbi Dr. Akiva Tatz in his teshuvah memoir, Anatomy of a Search. “He basically wrote my biography too,” avows Dr. Lebowitz, who is acquainted with Rabbi Tatz. “I still remember that image at the end of the book of someone putting on tefillin at Ohr Somayach, with the sun pouring in through the window.” He spent some months at Aish, which he describes as a “heady, wonderful time,” then began dividing his time between his residency in the U.S. and learning Torah in Israel.

After medical school, Lebowitz spent five years on the faculty of Harvard Medical School. He married, and moved back to Eretz Yisrael to learn in the Mirrer Yeshiva and be close to his rebbi, Rabbi Yitzchak Berkowitz. While he tried to avoid practicing medicine during that time, he found himself constantly solicited for consulting on various cases. Finally, after a few years, he was recruited by the Barnabas Health network to join the teaching faculty at Monmouth Medical Center in Long Branch, New Jersey, with a view toward servicing the growing frum population of Lakewood.

He teamed up with businessman Dan Czermack to open the first LTAC facility there in 2004, with 25 beds. In 2009, they opened another 25-bed facility at Kimball Hospital (now Monmouth South) in Lakewood. Four years ago the two separate facilities were consolidated into one 50-bed entity in Lakewood. While housed in Monmouth South, the facility is a separate entity with its own staff, leasing space and purchasing services from the hospital.

For the past 20 years, since his return from Jerusalem, Dr. Lebowitz follows the same schedule: He learns the morning seder in yeshivah, then devotes himself to patients. He attributes much of the ability to carry on his mission to his wife, an akeres habayis who supports his work and understands when family plans are interrupted by last-minute emergencies.

Wall of Pain

Dr. Lebowitz sees his facility as an extension of a larger Jewish network of chesed, encompassing Bikur Cholim, Hatzolah, and Chayim Aruchim. “Our goal is to give the longest and best care for patients,” he says.

“The world at large thinks we’re crazy,” Mrs. Horowitz comments. “They want to write off patients. Often it’s a billing issue — hospitals get paid per episode, not per day, so each day a person continues in care means less money for them.” If they don’t see a discharge in sight, they push for hospice. And so, she urges, “Know your rights. Don’t let them intimidate you.”

Simply by upholding a patient’s right to life, Dr. Lebowitz and Chayim Aruchim change the conversation in a world in which “quality of life” is considered the standard that makes life valuable.

Dr. Lebowitz will give top care to patients in their late nineties with no discharge in sight, believing only halachah should determine when it’s time to draw the line on treatment. To that end, he is in regular contact with poskim all over the world, often bringing them to Rav Dovid Morgenstern or Rav Yitzchak Berkowitz in Eretz Yisrael. “We have sh’eilos every day,” he says. “We’re always dealing with balancing risks and benefits, end-of-life issues, deciding on the intensity of care to give with each diagnosis. He cites one instance in which two elderly women were brought in on ventilators, and both developed a need for dialysis. Each family used a rav who was a well-recognized posek, yet after both spoke at length to Dr. Lebowitz about the patients’ condition, one of them instructed him to initiate dialysis and the other told him not to.

He adds that the ability of a family to accept and deal with these difficult situations is a reflection of their strength. Families have to toggle between their desire to keep their loved ones around forever and the acceptance that death is an inevitable part of life. He himself has to toggle between “relating to the fact that life is a gift of ineffable sanctity, and the physiology at the patient’s bedside… Most people know only one side of this dichotomy.”

Seeing his mission as one of chesed, he is adamant that his staff exhibit the utmost compassion for patients and their families, even as the prognosis often looks bleak. When patients and their families are in crisis, he says, it’s about more than getting the medical aspect right. He tells his staff, “Imagine having the absolute worst day of your life. Then you can imagine what these families are going through.” While he acknowledges that it’s emotionally taxing to provide compassionate care day in and day out, he nevertheless insists on it.

“I’m willing to excuse a learning curve on technical aspects of care, but not on gruffness and insensitivity,” he says. “In our facility, there’s just no room for a lack of empathy. A patient once told me she’d been cared for by 32 staff members, and she loved all but one of them. We called in that staff member, and in the course of our meeting, he said other things that displeased me, so I had to fire him.” He adds that it’s not just what the staff say to patients that counts; it’s also how they touch patients, turn them, wash them.

With such discouraging prognoses for many of his patients, it’s hard to imagine that Dr. Lebowitz wouldn’t walk out of his facility feeling down and depressed at the end of the day. But in fact, he says he feels invigorated when he can really be there for patients, gratified to be engaged in such meaningful work — although when the pressure and emotional fallout builds up, he has one recourse: “A few times a year, I take all my unaddressed pain, I go to the Kosel, and let it out.”

At the beginning, he admits, he suffered greatly from the pressure of so much responsibility. But he has since made his peace with his own limitations and accepted that outcomes are ultimately in Hashem’s hands, not his. “I have an obligation to do my hishtadlus, but that is no guarantor of the result,” he says. “I try to do my absolute best, and not accept either too much credit or too much blame.” He’s seen too many times when a patient he expected to do well did poorly, or vice versa. “One patient came in with multiple organ failure. We didn’t think it was possible that he’d pull through, but he did, and went home,” he says. “The longer I do this, the more humility I have.”

And he does see his share of miracles. Leah Horowitz recalls a time she received a call to help with a patient in his fifties who had lung cancer. The hospital treating him didn’t want to bother intubating him, preferring to simply let him die. When Mrs. Horowitz threatened to contact the press, they put him on a respirator, but did little else. After being transferred to Dr. Lebowitz, the man was successfully weaned off the respirator and was able to go home.

“He didn’t have an easy time,” she remembers. “There were easier moments and harder moments, but he was quite often awake and alert, and he lived three and a half years more. To his family, that meant the world.”

Another patient, a chassidic man in his seventies, came in after a massive stroke which left him paralyzed on one side of his body, unable to breathe on his own and unable to communicate. “The road was rough, with setbacks and complications along the way,” Dr. Lebowitz says. “He needed time, proactive care, and a team that believed in his recovery. He left our unit off the ventilator, talking, and was doing well enough to enter acute rehab. He’s now living back in his community in Boro Park.”

Does he have any sense of what makes the difference between patients who improve and those who decline? He hesitates. “Well, there are some physiological factors, as well as psychological ones, like the will to live,” he says. “But I’m still not good at predicting, and I can say, without exaggeration, that I’ve taken care of more vent patients over the past 15 years than anyone.”

One patient, a referral from Maimonides, came in on a respirator after a stroke. “He’ll walk again!” his family insisted. Dr. Lebowitz gently tried to explain that the chances were slim, but the family continued to insist he’d yet be up on his feet.

“I thought they just weren’t getting it,” he says. “But in the end we did wean him off the vent, and now he’s back in Brooklyn — it was a rocky road, but he’s much improved.”

How then, does he know when a family is simply in denial, or when their insistence should be taken seriously? By now, he’s seen too many logic-defying outcomes to contradict anyone. “If they claim their loved one will walk or speak again, against every shred of evidence we have, I just answer ‘Amen.’”

(Originally featured in Mishpacha, Issue 704)